I, ___________, declare that I am the plaintiff in the above-entitled proceeding; that, in support of my request to proceed without prepayment of fees under 28 U.S.C. section 1915, I declare am unable to pay the fees for these proceedings or give security therefor and that I am entitled to the relief sought in the complaint.

In support of this application, I answer the following questions under penalty of perjury: Are you currently incarcerated? Yes No (If "no" DO NOT USE THIS FORM) State the place of your incarceration.

Are you currently employed (includes prison employment)? Yes No

a. If the answer is "yes" state the amount of your pay.

b. If the answer is "no" state the date of your last employment, the amount of your take-home salary or wages and pay period, and the name and address of your last employer.

Have you received any money from the following sources over the last twelve months?

a. Business, profession, or other self-employment: Yes No

b. Rent payments, interest or dividends: Yes No -1-

c. Pensions, annuities or life insurance ...

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